Rescheduling Part 2 of the 11+ Reduces Injury Burden and Increases Compliance in Semi-Professional Football
Whalan M, Lovell R, Steele JR, & Sampson JA. Scand J Med Sci Sports. 2019; published online ahead of print. DOI:10.11111/sms.13532
Take Home Message
Soccer teams that completed the strength portion of the 11+ program at the end of a training session had better compliance and fewer ankle and severe injuries.
Soccer players who complete the 11+ program can reduce the risk of injury by more than 40%. Despite the effectiveness of the 11+ program, adoption and compliance are poor partly because of the time required to complete the program and concern about fatigue from the warm-up. Hence, these authors compared the compliance and effectiveness of the 11+ program among semi-professional teams when the program was offered traditionally or modified with parts 1 and 3 before training and part 2 (the strengthening portion) at the end of training. The researchers trained one person with each team to record when a player completed the 11+ program at a session, injury data (e.g., time loss, severe injuries, injury locations) and exposure data (hours of soccer). Each team performed the 11+ program at least twice per week during the 2017 season. Among the 25 teams, 2 teams that performed Part 2 after training and 3 teams that performed the traditional program failed to finish the study. Overall, the compliance was better among teams that performed Part 2 at the end of training (29 sessions vs. 19 sessions per player). However, compliance was still low to moderate for each group. The traditional program completed the 11+ program at only 33% of training sessions, and the other group completed the 11+ program at 58% of training sessions. The authors observed no differences between groups based on the number of total injuries. However, the teams that performed the modified 11+ with part 2 later had less total days lost (5,815 days vs. 4,303 days) probably because this group had fewer severe injuries (> 28 days lost). The modified 11+ also had lower ankle and recurrent injuries, but the standard 11+ had lower quadriceps muscle injuries and contusions.
This study is very interesting because it demonstrates that the 11+ program can be done at different times during a training session and still reduce the risk of injury. This is outstanding news because one of the barriers to the 11+ program is the completion of the strengthening exercises before activity on the field/court. Based on these new findings, teams can perform these activities after the activity so that they feel more comfortable about completing these. This may explain why compliance was improved with this approach. It would be interesting to know if the Part 2 program could even be performed in the weight room instead of on-field. It would be interesting to compare whether there would be any difference in injuries when both groups performed the same number of 11+ sessions. Furthermore, it would be interesting to pair this new approach to the 11+ program to other strategies to maximize compliance. Clinicians should work with coaches to tailor injury prevention programs to fit each team. This study addresses some of the concerns about the 11+ program, and coaches should be informed that it is acceptable to perform some of the program after practice.
Questions for Discussion
Are there other barriers to the 11+ that you think exist? Do you think it would make a difference if the strengthening portion were performed on the field or in the weight room?
Written by: Nicole M. Cattano
Reviewed by: Jeffrey Driban
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I believe another barrier that may exist beyond compliance to the FIFA 11 is improper form or technique by untrained individuals during the strength portion. One way to alleviate this concern is to have a FIFA 11 certification become mandatory for the leader of the program whether that is a coach, captain, or strength and conditioning coach. Compliance for this requirement can be increased by allocating time during the pre-season to have this accomplished. Additionally, the Sports Medicine Director at a club/school could ensure a coach seminar focusing on the FIFA 11 is made mandatory before the beginning of every season.
I believe there could be a substantial difference in compliance and success rates if the FIFA 11 were performed in the weight room as opposed to the field. As high schools, colleges, and professional teams are employing strength and conditioning coaches more frequently, the strength portion of the FIFA 11 can be taken over by the strength and conditioning coach ensuring a qualified professional administers the warmup.
Another barrier to the 11+ that exists is adherence to the program. My experience as a student AT has exposed me to various coaching styles. Often it appears that the coaching approach to warm up is laxed and hands off. Ensuring adherence to the program requires significant buy in from the coaching staff and team leadership. If leadership remains indifferent minimal adherence will be observed. I have had several athletes request a that I speak to the coach to have a more comprehensive and dynamic warm up added to their training regimen. With minimal effort I believe this program could be incorporated into more collegiate programs. I believe the largest barrier to its inclusion is awareness. If presented with the data and research I believe more coaches would be willing to incorporate the regimen into their practices.
The claim that “[d]espite the effectiveness of the 11+ program, adoption and compliance are poor partly because of the time required to complete the program and concern about fatigue from the warm-up” appears to be based on speculation. I would like if self-reported data was available as of to why the program was not adhered to. If we can understand why the program was not adhered to we could make adjustments to the program and ensure greater compliance.
The fact that the research only required the program to be performed twice per week appears to be a significant weakness of the study and the results obtained. As a student its been repeated to me time and time again that the minimal requirement for strength, flexibility, and endurance progression is three times per week. I would love further information on why the research only required the program to be conducted twice a week, and how this minimal requirement was able to effectively reduce injuries by up to 40%.
It would be interesting to see how beneficial this program would be if incorporated into a return to play protocol for an injury such as an ACL tear. This would allow the athletic trainer to control the administration of the program, ensure compliance, and instill confidence in the program.
Hi Andrew – thanks for your interest in the post and this research study. I agree with much of what you bring up, and think that this particular research study really does help enforce the ability of the strength portion to be completed in the weight room in a supervised fashion with coaches and/or strength coaches being more hands-on.
Sometimes it is difficult to change a particular teams’ culture in regards to the warm up, but hopefully with enough education and evidence, you can sway it a little to understand the importance of this program.
There was a research study that utilized concept mapping that we featured on SMR a while back that identified quite a few barriers to implementation and adherence. https://www.ncbi.nlm.nih.gov/pubmed/29353246 So while it may be seemingly speculative, the main themes from this research identified coach knowledge and leadership (as you mentioned), as well as sport specific goals/drills, and time at training.
While a lot of research in this area does enforce that frequency is important – work by Soligard 2008 & Steffen 2013 has shown that 2 – 3 times per week can still be effective in reducing injuries.
I really like the idea of incorporating some of these activities in a return to play protocol. Thanks for sharing some of your ideas and thoughts!